The statistics tell the story: Rates of opioid use disorder (OUD) and its consequences continue to rise. Yet we have effective treatments: methadone, buprenorphine, and naltrexone. And data show that effective treatment reduces not only opioid use, but overdose deaths, and other consequences of opioid misuse.
Moreover, we have opioid treatment programs (OTPs) that provide medical and psychosocial services as well as medications. In fact, OTPs offer all three medications—they’re the only programs that do—so health care providers can select the best treatment for each patient.
| OUD Data (2017)
Deaths from opioid overdose: 47,600 Past-year opioid use disorder: 2.1 million Misuse of Rx opioids, or heroin use: 11.4 milliona |
aAged 12 years or older.
It’s Not “Breaking News”
None of this is “breaking news.” So a team of experts wondered what was going on—why weren’t those OUD statistics going down, instead of up?”
They knew that OTPs could play a pivotal role in the opioid crisis; they could help turn things around. But, they wondered, how to leverage OTPs in the opioid response?
The team decided to find out, in the best way they knew of. What they needed was a clear current picture of OTPs; their characteristics and practices. And so they designed some questions, conducted a national electronic survey of U.S. OTPs, and published the results. “Characteristics and Current Clinical Practices of Opioid Treatment Programs in the United States” appeared online October 17 2019 in Drug and Alcohol Dependence.
The Research Team
Heading the research team was Christopher M. Jones, PharmD, DrPH, senior advisor at the Centers for Disease Control and Prevention (CDC), and associate director, Office of Strategy and Innovation. Other team members: five experts from the Substance Abuse and Mental Health Services Administration (SAMHSA), among them Elinore F. McCance-Katz, MD, PhD, head of SAMHSA, and assistant secretary for mental health and substance use at the Department of Health and Human Services. A long-time advocate of OTPs, Dr. McCance-Katz considers the additional support OTPs provide patients as being “crucial to recovery.” (https://atforum.com/2018/04/an-interview-with-dr-mccance-katz-on-importance-of-medications-and-psychosocial-treatment/)
The Study
The team’s queries took the form of a 46-question survey. All 1,605 OTPs in the U.S. were eligible to take the survey; 497 (31%) responded. Data were collected between August 2018 and October 2018.
The Good News
The survey revealed several encouraging findings. Only a small percentage of the OTPs responding had waiting lists. Also, 82% of the OTPs said they have DATA 2000-waivered providers on staff, and many OTPs were screening for and treating co-occurring substance use disorders (SUDs) (see chart directly below). A smaller percentage were linking with other providers or services, as shown in the second chart below.
| % of OTPs That Screen for and Treat Co-occurring SUDs |
|
|---|---|
| Drug screening | 87 to 99a |
| Treating co-occurring drug use disorders | 81.8 |
| Screening for alcohol use | 92.4 |
| Treating alcohol use disorder | 35.6 |
aPercentages of OTPs screening for illicit drugs were 99.0; for cannabis, 87.2; for prescription drug misuse, 96.6.
| % of OTPs That Provide Formal Linkages With Other Providers or Services |
|
|---|---|
| With primary care providers, for co-occurring physical health conditions | 67.5 |
| With community behavioral health providers, for co-occurring mental disorders | 74.7 |
| With the criminal justice system, for legal services | 52.7 |
| With telemedicine services, for remote health care | 22.7 |
Other important findings involved OTP services and practices. Changes by OTPs in these areas could have an especially beneficial impact on the characteristics of opioid use and OUDs.
Areas Where OTPs Could Help by Improving Policy Barriers
- Only about one-third of OTPs offered all three medications
- Relatively few used buprenorphine and extended-release (injectable) naltrexone
- Most did not offer important ancillary services; this category included transportation, job training and placement, help with housing, and childcare during treatment sessions
- More than three-fourths reported barriers to accepting new patients
| % of OTPs That Dispense Medications For OUD Treatment |
|
|---|---|
| All three medications | 32.4 |
| Methadone | 95.8 |
| Buprenorphine | 61.8 |
| Naltrexone | 43.9 |
HIV and viral hepatitis. Most OTPs provided HIV risk-reduction education (86.8%) and testing services (60.7%). More than 90% of OTPs provided some type of viral hepatitis services, including risk-reduction education (85.9%) and testing (60.9%).
But when it came to preventive services and treatment, it was a different story. About 15% of OTPs provided hepatitis B and A vaccination, and about 12% provided treatment for hepatitis C infection.
A finding that particularly concerned the team was “the extremely low percentage of OTPs providing treatment or preventative services for HIV or viral hepatitis, with approximately 1 in 10 offering HIV PrEP [a pre-exposure preventive medication], 1 in 12 offering medication treatment for HIV, 1 in 7 offering hepatitis A or B vaccination, and 1 in 8 offering medication treatment for HCV.” The authors emphasized the need for “better integrating HIV and viral hepatitis prevention, testing, and treatment services into OTPs.” Also mentioned was the need to integrate infectious disease services, as few OTPs offered services related to HIV or viral hepatitis; and to “expand the reach of OTPs.”
Barriers to Treatment
About three-fourths of OTPs reported at least one barrier to treatment. Most common: insurance requirements and reimbursement policies, and the physical constraints of the OTP. Each of these was cited by about one-fourth of the OTPs. Next, in order of frequency: not enough behavioral health provider staff, lack of patient demand, insufficient medical staff (physician or other medical provider). Approximately 10% of responders cited barriers related to funding or regulatory concerns. The team recommended changes in policy payments—providing broader insurance coverage for OTP treatment, and establishing stipulations, such as eliminating arbitrary insurer requirements for prior authorization.
OTPs could educate and train staff members, as a way to help clinicians feel more comfortable about using buprenorphine and extended-release naltrexone injection. Also, patients could be educated about the benefits and risks of each medication.
Responding to the topic of barriers to accepting new patients, OTPs cited state and local regulations for the most part, but mentioned federal regulations as well. The authors noted, “Efforts are needed to support regulatory requirements that facilitate the implementation and expansion of OTPs while also ensuring appropriate regulatory oversight of OTPs.”
Conclusions
The authors underscored the need “to make all medications approved to treat OUD available in OTPs, and to integrate services related to infectious disease. A third recommendation: “expand the reach of OTPs in the U.S.”
Several areas were identified as urgent needs—
- Making a greater effort to train clinicians and incentivizing them to provide care at OTPs
- Making sure OTPs are complying with regulatory requirements
- Adopting appropriate changes in delivery models and payment reforms
- Supporting education of patients and the public on use of OTP medications, and the availability of OTPs
Reference
Jones CM, Byrd DJ, Clarke TJ, et al. Characteristics and current clinical practices of opioid treatment programs in the United States. Drug Alc Depend. 2019;205:107616. https://doi.org/10.1016/j.drugalcdep.2019.107616